Cited by 286Cardiac and Coronary Surgery TechniquesMechanical Circulatory Support DevicesCardiac, Anesthesia and Surgical Outcomes

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Predictors of low cardiac output syndrome after coronary artery bypass

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Rao, Vivek, Ivanov, Joan, Weisel, Richard D., Ikonomidis, John S., Christakis, George T., David, Tirone E.·1996·The Journal of Thoracic and Cardiovascular Surgery

DOI 10.1016/s0022-5223(96)70176-9

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Abstract

The purpose of this study was to identify patients at risk for the development of low cardiac output syndrome after coronary artery bypass. Low cardiac output syndrome was defined as the need for postoperative intraaortic balloon pump or inotropic support for longer than 30 minutes in the intensive care unit to maintain the systolic blood pressure greater than 90 mm Hg and the cardiac index greater than 2.2 L/min per square meter. The preoperative patient characteristics that were independent predictors of low cardiac output syndrome were identified among 4558 consecutive patients who underwent isolated coronary artery bypass at The Toronto Hospital between July 1, 1990, and December 31, 1993. The overall prevalence of low cardiac output syndrome was 9.1% (n = 412). The operative mortality rate was higher in patients in whom low cardiac output syndrome developed than in those in whom it did not develop (16.9% versus 0.9%, p < 0.001). Stepwise logistic regression analyses identified nine independent predictors of low output syndrome (percent frequency in parentheses) and calculated the factor-adjusted odds ratios associated with each predictor: (1) left ventricular ejection fraction less than 20% (27%, odds ratio 5.7); (2) repeat operation (25%, odds ratio 4.4); (3) emergency operation (27%, odds ratio 3.7); (4) female gender (16%, odds ratio 2.5); (5) diabetes (13%, odds ratio 1.6); (6) age older than 70 years (13%, odds ratio 1.5); (7) left main coronary artery stenosis (12%, odds ratio 1.4); (8) recent myocardial infarction (16%, odds ratio 1.4); and (9) triple-vessel disease (10%, odds ratio 1.3). Low cardiac output syndrome is a clinical outcome that may result from inadequate myocardial protection or perioperative ischemic injury. Patients at high risk for the development of low cardiac output syndrome should be the focus of trials of new techniques of myocardial protection to resuscitate the ischemic myocardium.

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Miura, N., Yoshitani, K., Kawaguchi, M., Shinzawa, M., Irie, T., Uchida, O., Ohnishi, Y., & Mackensen, G. B. (2009) · Journal of Anesthesia · doi:10.1007/s00540-009-0794-8 · Cited by 10
“2 l·min·m has been used as a defi nition of low cardiac output syndrome [19–21], we selected SvO2 of 70% and CI of 2.”
Method
Low postoperative mitochondrial oxygen tension is an early marker of acute kidney injury after cardiac surgery: A prospective observational study
Hilderink, B. N., Crane, R. F., Arbous, M. S., van den Bogaard, B., Pillay, J., & Juffermans, N. P. (2025) · Journal of Critical Care · doi:10.1016/j.jcrc.2025.155088 · Cited by 9
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Lin, C., Wu, M., Tsai, F., Chu, J., Chang, Y., Haung, Y.-K., Liu, K., & Lin, P. J. (2010) · PubMed · Cited by 9
Timing of levosimendan in cardiac surgery.
Aksun, M., Karahan, N., Adanır, T., Aran, G., Yetkin, U., Oztürk, T., Şencan, A., Özgürbüz, U., & Gürbüz, A. (2009) · PubMed · Cited by 9
Outcome of women is impaired in patients undergoing emergency coronary artery bypass grafting for failed PTCA
Reinecke, H., Roeder, N., Schmid, C., Fischer, J., Scheld, H. H., BREITHARDT, G. E., & Kerber, S. (2001) · Zeitschrift für Kardiologie · doi:10.1007/s003920170092 · Cited by 9
“These observations are in good accordance to others who showed that female gender was a major predictor for operative mortality and especially for low output failure after CABG (18).”
Result
Sex differences in resource use after on-pump and off-pump coronary artery bypass surgery: A propensity score-matched cohort
Maganti, M. D., Rao, V., & Cusimano, R. J. (2009) · Canadian Journal of Cardiology · doi:10.1016/s0828-282x(09)70498-2 · Cited by 9
“As previously described (2), CPB was maintained using sodium nitroprusside, phenylephrine or noradrenaline as required to maintain a mean arterial pressure of greater than 65 mmHg and CPB flows of greater than 2.”
Method
One-shot cardioplegia for minimally invasive mitral valve repair-a comparison of del Nido and Bretschneider Histidine-Tryptophan-Ketoglutarate solutions
Gerber, W., Sanetra, K., Drzewiecka-Gerber, A., Jankowska-Sanetra, J., Kuczera, M., Białek, K., Buszman, P. P., & Bochenek, A. A. (2022) · Perfusion · doi:10.1177/02676591221080653 · Cited by 8
“The question whether statistical significance becomes apparent in higher number of patients is important, as low cardiac output syndrome in an important predictor of mortality and morbidity, which may be increased 10-to 17-fold.(16) One study already showed that fewer patients required inotropic support when using the…”
Result
Risk factors for postoperative myocardial injury-related cardiogenic shock in patients undergoing cardiac surgery
Cheng, X., Wang, K., Zhang, H.-T., Zhang, H., Jiang, X., Lu, L., Chen, C., Cheng, Y.-Q., Wang, D., & Li, K. (2023) · Journal of Cardiothoracic Surgery · doi:10.1186/s13019-023-02312-3 · Cited by 9
“Background The incidence of cardiogenic shock after cardiac surgery is approximately 3-9% [1, 2].”
Background
Prolonged cardiovascular pharmacological support and fluid management after cardiac surgery
Kontar, L., Beaubien‐Souligny, W., Couture, É. J., Jacquet‐Lagrèze, M., Lamarche, Y., Levesque, S., Babin, D., & Denault, A. Y. (2023) · PLoS ONE · doi:10.1371/journal.pone.0285526 · Cited by 9
Use of intra-aortic balloon pump in cardiac surgery: analysis of 80 consecutive cases
Júnior, F. P., Tagliari, A. P., Luvizetto, A. B., Pereira, E. M. C., Siliprandi, E. M. O., Nesralla, I. A., dos Santos, R. P., & Kalil, R. A. K. (2012) · Brazilian Journal of Cardiovascular Surgery · doi:10.5935/1678-9741.20120041 · Cited by 8
“Thus, the development of this syndrome represents revascularization or inadequate myocardial protection and can act as a marker of perioperative myocardial injury [13].”
Background
Coronary Artery Bypass Grafting
Al‐Atassi, T., Toeg, H. D., Chan, V., & Ruel, M. (2016) · Elsevier eBooks · doi:10.1016/b978-0-323-24126-7.00088-0 · Cited by 8
Rationale, design and baseline characteristics of the PRO-TECT II study: PROpofol CardioproTECTion for Type II diabetics
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Aprotinin and Dipyridamole for the Safe Reduction of Postoperative Blood Loss
Cohen, G. N., Ivanov, J., Weisel, R. D., Rao, V., Mohabeer, M. K., & Mickle, D. A. G. (1998) · The Annals of Thoracic Surgery · doi:10.1016/s0003-4975(97)01428-8 · Cited by 8
Inotropes for the prevention of low cardiac output syndrome and mortality for paediatric patients undergoing surgery for congenital heart disease: a network meta-analysis
Burkhardt, B. E. U., Hummel, J., Rücker, G., & Stiller, B. (2024) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd013707.pub2 · Cited by 7
Insuficiencia ventricular derecha en el seno de la cirugía cardiaca
Peiretti, M. A. C., Vela, J. L. P., & Carreño, E. R. (2013) · Revista Española de Cardiología Suplementos · doi:10.1016/s1131-3587(13)70082-7 · Cited by 7
The top 100 manuscripts in emergency cardiac surgery. Potential role in cardiothoracic training. A bibliometric analysis
Karsan, R. B., Powell, A. G. M. T., Nanjaiah, P., Mehta, D., & Valtzoglou, V. (2019) · Annals of Medicine and Surgery · doi:10.1016/j.amsu.2019.05.002 · Cited by 7
OXIDATIVE STRESS IN CARDIAC SURGERY
Grebenchikov, O. A., Zabelina, T. S., Filippovskaya, Z. S., Gerasimenko, O. N., Ovezov, A. M., Plotnikov, E. Y., & Likhvantsev, V. V. (2016) · Messenger of Anesthesiology and Resuscitation · doi:10.21292/2078-5658-2016-13-4-53-60 · Cited by 7
Extracorporeal Life Support in Postcardiotomy Cardiogenic Shock: A View on Scenario, Outcome, and Risk Factors in 261 Patients
Provazník, Z., Philipp, A., Zeman, F., Camboni, D., Schmid, Ç., & Floerchinger, B. (2020) · The Thoracic and Cardiovascular Surgeon · doi:10.1055/s-0040-1714746 · Cited by 7
The need for inotropic drugs in anesthesiology and intensive care.
Via, G., Veronesi, R., Maggio, G., & Braschi, A. (2003) · PubMed · Cited by 7
Low output syndrome following aortic valve replacement. Predictors and prognosis
Banach, M., Goch, A., Rysz, J., Barylski, M., Jaszewski, R., & Goch, J. H. (2007) · Cited by 7
Incidence, factors, and prognostic analyses of challenging cardiopulmonary bypass separation in Chinese cardiac surgical populations
CHEN, D. X., WANG, T. H., Xiong, X., Shi, J. C., & Zhou, L. (2023) · Minerva Anestesiologica · doi:10.23736/s0375-9393.23.17727-3 · Cited by 6
Cardiac Surgery in the Elderly: Indications and Management Options to Optimize Outcomes
Conti, V. R., & Lick, S. D. (2006) · Clinics in Geriatric Medicine · doi:10.1016/j.cger.2006.04.001 · Cited by 6
Genome-Wide Assessment for Genetic Variants Associated with Ventricular Dysfunction after Primary Coronary Artery Bypass Graft Surgery
Fox, A. A., Pretorius, M., Liu, K.-Y., Collard, C. D., Perry, T. E., Shernan, S. K., Jager, P. L. D., Hafler, D. A., Herman, D. S., DePalma, S. R., et al. (2011) · PLoS ONE · doi:10.1371/journal.pone.0024593 · Cited by 6
“Although clinical parameters such as preoperative LVEF and duration of CPB are predictive of risk for developing postoperative VnD [3,5], other unknown factors are expected to contribute to postoperative cardiac dysfunction.”
Practice pattern variability for myocardial revascularization: Impact on resource use across 24 centers
Savino, J. S., Ley, C., Boisvert, D., Friedman, A., Mathew, J. P., Koch, C. G., Starr, N. J., Mangano, C. M., Herskowitz, A., Browner, W. S., et al. (2002) · Journal of Cardiothoracic and Vascular Anesthesia · doi:10.1053/jcan.2002.31055 · Cited by 6
Late Results of the Warm Heart Trial
Fremes, S. E., Tamariz, M. G., Abramov, D., Christakis, G. T., Sever, J. Y., Sykora, K., Goldman, B. S., Feindel, C. M., & Lichtenstein, S. V. (2000) · Circulation · doi:10.1161/circ.102.suppl_3.iii-339 · Cited by 6
Routine Reoperative Off-Pump Coronary Artery Bypass Grafting Via Midline Sternotomy: Is It Feasible?
Hirose, H., Amano, A., Ru-zheng, L., & Xiang, Z. (2005) · Angiology · doi:10.1177/000331970505600301 · Cited by 6
Does the pre‐ischaemic administration of sevoflurane reduce myocardial stunning? A porcine experimental model
Aagaard, S. R., Larsen, J. R., Berg, J. S., Sloth, E., & Hasenkam, J. M. (2007) · Acta Anaesthesiologica Scandinavica · doi:10.1111/j.1399-6576.2007.01288.x · Cited by 6
“These findings indicate that sevoflurane could be used to protect the myocardium against ischaemic damage during cardiac surgery where myocardial stunning (6–9) and a low cardiac output (CO) state (10, 11) are well-known conditions.”
Background
Improved early risk stratification of deep sternal wound infection risk after coronary artery bypass grafting
Kamenšek, T., Kališnik, J. M., Ledwon, M., Santarpino, G., Fittkau, M., Vogt, F. A., & Žibert, J. (2024) · Journal of Cardiothoracic Surgery · doi:10.1186/s13019-024-02570-9 · Cited by 5
“…index to less than 2.2 L/min/m 2 requiring inotropic agents and / or mechanical circulatory to maintain the systolic blood pressure higher than 90 mm Hg and the cardiac index greater than 2.2 L/min/m 2 after optimizing and correcting preload, afterload, electrolyte and blood gas abnormalities [22].”
BackgroundInfluential
Percutaneous Mechanical Assist Devices for Severe Left Ventricular Dysfunction
Mulukutla, S. R., Pacella, J. J., & Cohen, H. A. (2002) · Humana Press eBooks · doi:10.1007/978-1-59259-154-1_19 · Cited by 5
Factores de predicción del uso de soporte inotrópico en cirugía cardiaca
Morales, C. (2008) · Colombian Journal of Anesthesiology · doi:10.1016/s0120-3347(08)62002-x · Cited by 5
Major adverse cardiac events after first time elective isolated coronary artery bypass grafting: A retrospective cohort study
Kamel, A. T. H., Hassouna, A., Mourad, H. E.-D. A. A.-H., & Hikal, T. S. (2018) · Journal of the Egyptian Society of Cardio-Thoracic Surgery · doi:10.1016/j.jescts.2018.11.001 · Cited by 5
Del Nido versus cold blood cardioplegia in adult patients with impaired ejection fraction undergoing valvular and complex heart surgery
Sanetra, K., Gerber, W., Domaradzki, W., Mazur, M., Synak, M., Pietrzyk, E., Buszman, P. P., Kaźmierczak, P., & Bochenek, A. A. (2022) · The Journal of Cardiovascular Surgery · doi:10.23736/s0021-9509.22.12498-5 · Cited by 5
National Estimates for the Percentage of All Readmissions With Demographic Features, Morbidity, Overall and Gender-Specific Mortality of Transcutaneous Versus Open Surgical Tricuspid Valve Replacement/Repair
Khan, M. S., Baqi, A., Tahir, A., Ghumman, G. M., Ullah, W., Shah, J., Sattar, Y., Mir, T., Sheikh, Z., Salman, F., et al. (2024) · Cardiology Research · doi:10.14740/cr1625 · Cited by 5
“Data show that during cardiac surgery, around 0.2% to 6% of patients can develop post-cardiotomy cardiogenic shock, which is characterized by tissue hypo-perfusion and end-organ damage despite adequate preload [40].”
BackgroundInfluential
Prolonged QTc affects short-term and long-term outcomes in patients with normal left ventricular function undergoing cardiac surgery
Anantasit, N., Boyd, J. H., Russell, J. A., Fjell, C. D., Lichtenstein, S. V., & Walley, K. R. (2014) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2013.11.043 · Cited by 5
Cardiac Surgery and Diabetes Mellitus
Khan, T., Voisine, P., & Sellke, F. W. (2005) · Humana Press eBooks · doi:10.1385/1-59259-908-7:543 · Cited by 5
“Postoperative myocardial dysfunction appears to be exacerbated by diabetes as it is an independent predictor of postoperative low cardiac output syndrome ( 18 ).”
Background
Levosimendan in Acute Heart Failure: Past, Present, and Future
Delgado, J. F. (2006) · Revista Española de Cardiología (English Edition) · doi:10.1016/s1885-5857(06)60766-4 · Cited by 5
Comparison of prophylactic levosimendan versus intra-aortic balloon pump for off-pump coronary artery bypass grafting in patients with low ejection fraction: A randomized-controlled trial
Mate, R. (2020) · Cardiovascular Surgery and Interventions · doi:10.5606/e-cvsi.2020.834 · Cited by 4
“[10,11] All these changes are exaggerated intraoperatively in patients with LV dysfunction, which is the main risk factor for intra- and postoperative LCOS.”
Background
Risk factors for decreased cardiac output after coronary artery bypass grafting: a prospective cohort study
dos Santos, E. R., Lopes, C. T., Maria, V. L. R., & de Barros, A. L. B. L. (2016) · European Journal of Cardiovascular Nursing · doi:10.1177/1474515116681373 · Cited by 5
Inotropes for the prevention of low cardiac output syndrome and mortality for paediatric patients undergoing surgery for congenital heart disease: a network meta-analysis
Burkhardt, B. E. U., Hummel, J., Rücker, G., & Stiller, B. (2020) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd013707 · Cited by 4

Authors: Rao, V., Ivanov, J., Weisel, R. D., Ikonomidis, J. S., Christakis, G. T., & David, T. E.
Affiliations: University of Toronto (CA)
ORCID: Rao, Vivek
Ikonomidis, John S.
David, Tirone E.
Venue: The Journal of Thoracic and Cardiovascular Surgery
Publisher: Elsevier BV
Published: 1996-07
Volume: 112
Issue: 1
Pages: 38-51
ISSN: 0022-5223 (ISSN-L)
DOI: 10.1016/s0022-5223(96)70176-9
OpenAlex: W2072841444
Cited by: 286
References: 32
Citations by year: 2026: 4 · 2025: 7 · 2024: 6 · 2023: 14 · 2022: 6 · 2021: 9 · 2020: 15 · 2019: 7 · 2018: 11 · 2017: 9 · 2016: 10 · 2015: 7 · 2014: 12 · 2013: 9 · 2012: 17
FWCI: 5.41
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/open-access/userlicense/1.0/ (vor, 7310 d)
Locations: Journal of Thoracic and Cardiovascular Surgery (publishedVersion)
PubMed (publishedVersion)
Funders: Heart and Stroke Foundation of Canada
Medical Research Council Canada
Medical Research Council
Topics: Health Sciences › Medicine › Surgery › Cardiac and Coronary Surgery Techniques
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Mechanical Circulatory Support Devices
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
Keywords: low cardiac output syndrome, coronary artery bypass grafting, risk factors, left ventricular ejection fraction, reoperation, emergency surgery, female sex, diabetes mellitus, old age, left main coronary artery stenosis, recent myocardial infarction, three-vessel coronary artery disease, postoperative mortality, cardioprotection, perioperative myocardial ischemia, intra-aortic balloon pump, inotropic support
MeSH terms: Aged, Coronary Artery Bypass, Cardiac Output, Low, Female, Humans, Male, Middle Aged, Postoperative Complications, Prognosis, Prospective Studies, Sex Factors, Syndrome, Survival Rate, Odds Ratio, Ventricular Dysfunction, Left, Diabetes Complications

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Predictors of low cardiac output syndrome after coronary artery bypass

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